In scientific terms reflection is seen as light, heat or sound striking a surface to give off a reflection. Reflection is also seen as philosophical understanding of how one can gain knowledge through experience and use different approaches to the same scenario (Johns and Freshwater 2009 and Chambers et al 2012).
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The novel idea of reflection rose from a theorist John Dewey (1859-1952); his proposed view on reflection is described as persistent, active thinking and taking into consideration the supporting evidence that forms knowledge to the given situation. This theorist suggests that the person uses their mind and emotions to facilitate reflection (Bulman and Schutz 2008). This suggests that Dewey describes reflective individuals has being open-minded, responsible and wholehearted (Vachon and Leblanc 2011).
Dewey’s perception of reflection was a platform for many authors to elaborate on in terms of understanding reflective practice. Johns and Freshwater (2005) propose that health professionals should find the meaning of reflection through description rather than definition because to define reflection is to suggest the author has authority over its meaning. This in turn allows reflections models and frameworks to be used intuitively giving a more holistic approach, it can be subjective and purpose driven (Johns and Freshwater 2005).
Mann et al (2007) describes Schon’s (1983) view that reflection can happen in two ways: reflecting upon activities whilst they are happening called reflection in action (present reflection) and reflecting upon activities once they have happened (reflecting on the past). Rolfe et al assert that reflection is the engine that facilitates superficial learning into finding a deeper understanding that enables the practitioner to transform what is known to knowledge in action.
Reflection Model and frameworks
The reflection framework developed by Schon and Argyris (1992) involves three elements: (1) knowing-in-action (2) reflection-in-action and (3) reflection-on-practice (Ghaye and Lillyman 2010). Ghaye and Lillyman (2010) have extrapolated Schon’s work to include knowing-in-action; they propose that practitioners ‘customise’ and ‘tailor’ their own knowledge or theories to the situation presented. Knowing in action is described further by Carper (1978) who identifies five approaches to knowing in action; empirical, personal, ethical and aesthetic knowing ( Newton and McKenna 2009).
Reflection-in-action by Schon and Argyris (1992) has been adapted from Schon (1983) it is to do with reflecting in the moment without disturbing care. It involves thinking ‘on your feet’ Ghaye and Lillyman (2010) propose that whilst this may be a complex process it is by far the most effective when clarifying that needs of patients are being met. It is the way in which practitioners compose themselves to handle and resolve difficult situations when being faced with them (Schon 1992). This could entail thinking of what needs to be said to patients whilst talking to them already. Gustafsson and Fagerberg (2004) state that Schon (1983) believes reflection-in-action allows nurses to display a combined range of skills – abstract knowledge and clinical experience. This type of reflection is difficult to master as is challenge our knowing-in-action and is used by professional practitioners that have acquired technical skills over a number of years Rolfe et al (2011) and Ghaye and Lillyman (2010). Mann et al (2007) state that professional practitioners are able to reflect-in-action because they have the knowledge to do ‘interpretive orientation’ – monitoring, assessing and changing patient care on a continual basis. Mann et al (2007) also state that student nurses are limited to reflection in action because their experiences are not authentic and the role is supervised throughout thus students actions are questioned and changed if necessary to suit patient care. This is why critical reflection is important learning tool for students and can be facilitated by mentors, clinical supervisors.
Schon (1992) reflection-on-action is reflecting back on events taken place. The reflector can examine and analyse the events step by step either within self, discussion with another practitioner or within groups (Ghaye and Lillyman 2010). Greenwood (1998) take on reflection on action as ‘cognitive post-mortem’ this is where the practitioner goes back to review actions that were made during the events. Greenwood (1998) argues that reflection before action is not deemed important for this type of reflection and to be unable to reflect before action is considered erroneous as patient care and outcomes become influenced by these factors.
It is already known that Dewey was the first advocate of learning by reflection, Rolfe et al (2011) summarise Dewey’s (1938) model of reflective learning as experiencing through observing and reflecting on current or past events which leads to gaining new or enhancing knowledge. In modern healthcare however Gibbs (1988) model of reflection see appendix 1 is widely used which is an adaptation of Dewey’s (1938) original model. Gibbs (1988) model asks the practitioner to paint a picture of the event – describe what happened and attach emotions and thoughts to the event. Gibbs then prompts the practitioner to weight what was good or bad about the experience. The third aspect of the model is technical this part asks the practitioner to analyse the situation in the hope to uncover either new findings or confirm the current situation. The fourth aspect is about understanding and finding out what else could the practitioner have done to change the previous outcome of the situation being started and lastly the practitioner is prompted to write an action plan in case the same or similar scenario can take it our (McKinnon 2004). Although Gibbs model appears cyclical it is not clear as to how the action plan which concludes the reflection process is linked back to description (Rolfe et al 2011). Gibbs model of reflection give the practitioner simple and general cue questions which allows the practitioner room to expand their thoughts on also it the most widely used reflection model for student nurses (Bulman and Schutz 2009) in contrast Rolfe et al 2011 state that Gibbs model has a generic and unspecific feel therefore some reflective practitioners find Gibbs model to vague.
Holms and Stephenson (1994 see also Rolfe et al 2011) see appendix 2 shared similar assertions to Gibbs model and therefore they proposed another reflection framework consisting of better designed cue questions. Stephenson framework is aimed towards more on action rather than theorising outcomes. Rolfe et al (2011) suggest that Stephenson and Holms framework mirrors Dewey’s initial interpretation of learning by thinking. However neither Gibbs model or Stephenson framework encompass a clear guideline to how knowledge can be linked to practice apart from asking the practitioners to think about what they would if they encountered a similar situation again.
The framework set out by Johns (2004) is an adaptation of many frameworks and models by many authors (Johns and Freshwater 2005). John and Freshwater (2005) encompassed not only the different aspects of reflection such in-action and on-action but also mindful practice. Benner et al (1996) explains that mindful practice is seen as clinical judgement which is practitioners possessing the ability to see what is happening as it happening in a clinical environment that allows the practitioner to engage ethically with the situation. Johns (1995) framework also included reflexivity which asks the practitioner to revisit the situation and asks interpersonal questions that allow the practitioner to link previous experiences to the current situation. Johns and Freshwater (2005) see appendix 3 have managed to articulate a model of reflection which is structured and concise this model also impacts clinical supervision and can be used for mentoring purposes.
Taylor (2006) see appendix 4 illustrates its model of reflection by using the words REFLECT as mnemonic device where each letter is represents a process of how reflection can take place. Tacit knowledge is displayed in this type of reflection, it is knowledge that practitioners are unaware of possessing and only comes to light when reflecting about the decisions they have made either during or after the event Schon (1987). There is a sense of liberation attached to Taylor’s reflection as it also caused the practitioner to be accepting of news ideas and not to be confined to constraints Taylor (2006) uses a critical friend to encourage reflection. Taylor (2006) understands that changes in awareness is a sure possibility because new insights can arise through reflection this occurs by linking emotions and feelings furthermore it requests the practitioner to ask themselves what have they learnt from their experience. Taylor model of reflection is laid out in manner that demands structured critical reflection and requires a facilitator or critical friend to see the process through this could be a disadvantage because it can be a demanding procedure, not very empowering to challenge top ranking staff and a facilitator may not be available (Rolfe et al 2011).
Kolb (1984) see appendix 5 see also Rolfe et al (2011) model of reflection is directed towards experimental learning, Kolb model is set out such that it asks the practitioner to look beyond describing and observing past events but also to theorise on the reflective events to determine if new approaches can be addressed or implemented. Kolb’s classic model of experimental learning consists of four components; experience, observation/reflection, generalization and conceptualisation and active experimentation (Stonehouse 2011). When compared to Gibbs model this model is truly cyclical and reflexive because Kolb sets out to generate a hypothesis to test the clinical setting hence the practitioner is allowed to renew reflecting on the newly modified experience (Rolfe et al 2011).
Reflective practice is seen has using reflective techniques to improve, maintain changes in clinical procedures and influence guidelines to encourage greater safety of patients in all areas of health organisations (Bulman and Schutz 2008). Duffy (2007) states reflective practice must clearly be demonstrated by the practitioner for personal and professional development in nursing and other allied health professions.
Price (2004) states that nursing practices can be transformed by facilitating insight and reason by practitioners, Price (2004) also understands that workforces may also be doubtful of the wisdom behind changes to particular strategies for example changes to multidisciplinary team meetings held usually midweek could be changed to a day closer to the weekend and therefore the workforce may be doubtful of referrals being received on time to their relevant partners. Burns and Bulman (2000) and Johns (2000) assert that reflective practice whilst it is patient centred all addresses the untidiness and confusion of the clinical environment.
Benner et al (1996) adds functioning of the practice environment is not as clear cut as a science textbook. Johns (2005) states that learning though reflection leads to enlightenment – finding out who we are, empowerment – having courage to redefine who we are and emancipation – given freedom to make changes to achieve desirable effects. It is the role of clinical supervisors, preceptors and mentors to encourage and implement reflection and critical thinking within their practice environment (Price 2004). Reed (2008) state that mentors are able to support less experienced or new employees by sharing their experience with them and providing a higher level of knowledge and understanding of different work practices. Duffy (2007) uses Williams (2001) to suggest problem based learning provides stimulus for student nurses to develop their critical reflection skills.
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Continuing Professional Development
Health care organisations in the United Kingdom have undergone and still continue to undergo changes to how it is regulated (Rolfe et al 2011). The emphasis is largely associated with increasing patient safety and risk reduction (Rolfe et al 2011, Mantzoukas 2008). Evidence-based studies have taught the NHS and regulatory bodies how to change practices and procedures to create better outcomes for patients, they have also encompassed further development for staff to promote a better use of resources through clinical professional development (CPD) (Bulman and Schutz 2009).
The Healthcare Professionals Council (2012) and The Nursing Midwifery Council (2006) state that nurses and midwives must provide evidence and maintain competency levels to remain in employment as nurses and midwives every three years after registering. The NMC does not determine the nature or types of continuing professional development programs to undertake, it is the responsibility of the practitioner and organisation to do this (Gould et al 2006, Munro 2008). Munro (2008) claims self regulation is vital to professional development and is achieved by maintaining a portfolio constructed of professional and personal achievements and certificates of attendance to mandatory competency trainings. Leblanc and Vachon (2011) agree that continuing education programmes such as diabetic training, pressure sore management training and infection control training as well as MSc postgraduate courses such as tissue viability or nursing prescribing courses add to a professional competency portfolio.
Critical Incident Analysis
Reflective practice is deployed when undertaking critical incident analysis (CIA). Critical incidents can be either a surprise event (ref) or series of events that could trigger reflection (Hanning 2001). The analysis process enables the practitioner to pause and contemplate on the situation and to establish meaning to the situation. Critical thinking can be viewed as either negative or positive experiences (Price 2004) and therefore some practitioners have exhibited discomfort associated with critical incident analysis because the process can challenge what they thought they knew as best practice can have undesirable effects and evoke anger, grief, frustration and sadness (Rich and Parker 1995 see also Vachon and LeBlanc 2011). Critical incident events could be viewed as drug errors, nosocomial cross-infection or helping a patient achieve a comfortable, dignified death, closing of wards. However not all incidents have to be as grave as these. CIA can also be viewed as a significant incident where it does not pose immediate threat, however it causes the practitioner to reflect upon the situation in systematic manner (Ghaye and Lillyman 2010).
Non-verbal and verbal skills are used to demonstrate communication which is the sending and received of messages (McCabe 2004). In nursing communication is not only about transmitting information, nurse-patient relationship involves in the transmitting feelings and nurses need to be able to display the appropriate behaviour or manner to demonstrate that their feelings have been recognised (Sheppard 1993 cited in McCabe 2004). Attending behaviour is described by Stein-Parbury (2009) as being ready to listen, maintain good positioning, open body language, eye contact and facial expression these are all are signs of an outward physical manifestation which when a nurse displays is demonstrative of their genuine interest to know and understand their patient. Department of Health (2000) states that good communication between health providers and patients is essential for establishing high quality care. The most important attribute deemed by patients practitioner should have is ‘the willingness to listen to and explain’ patients concerns (Moore 2009).
According to the NMC (2010) the role of nurses is to use their clinical judgment in the provision of care which would enable patients to improve, maintain or recover their health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death. This is where reflection and critical incident plays a role in good communication and evolving our interpersonal skills.
Discussing a patient’s condition and advising them on the therapy available ot giving medication are example of reflection-in-action. Reflection in action causes the practitioner to slow down and think of how to approach the patient, they may assess the situation and decided to leave out medical jargon, and use simplified speech, (Kraszewski and McEwen 2010). There are no specific models to use for these examples it is more about how the practitioner relates to the patient to convey their message is important.
An example of reflection-on-action that enables practitioners to reflect on their communication skills is breaking-bad news. Bad-news has a variety of meanings attached to it ultimately it may leave the patient with fewer life choices (DHSSPS 2003). Guidelines are available to facilitate breaking of bad news. Guidelines are set out to help the practitioner conduct themselves in an empathetic manner it enables them to ensure the privacy and dignity of the patient have been maintained (DoH 2003). Unable to convey the message appropriately to patients and their families it leaves an indelible mark on the nurse-patient relationship (DHSSPS 2003). Breaking bad news is exhausting, emotionally draining and difficult task for practitioners (O’Leary 2010). Because of this it is best for staff to able to reflect upon the situation soon after the event with clinical supervisors, mentor or education facilitators (DHSSPS 2003).
From this study it can be confirmed that reflection has been widely sourced since John Dewey’s initial introduction. The models and frameworks of reflection all ask the practitioner to paint the picture of what happened in the clinical setting and asks the practitioner cue questions to make them relate their feeling and emotions experienced during, or after reflecting. Reflective models that end with action plans do not appear truly cyclical and models that form new hypothesis and allow experimentation to test the hypotheses are reflexive and cyclical. Some of the frameworks ask the practitioner to challenge social conflict within their organisations.
Becoming proficient in reflection helps practitioners nurse gain a greater edge for understanding patient care they can use this asset to becoming mentors and clinical supervisors. Reflective practice can be challenging and some may find it difficult if all we do is analyse what went wrong this is why it is also important to reflect on what was good in practice. Nurses need to provide evidence of continuing professional development they need to be able to withstand rigours checks to make sure the sustain their registration by the NMC using reflective practice within their clinical environment sets them up for achieving this. Reflective practice using either critical incident analysis or emancipatory reflection aids in learning about communication.
Reflective practice can open doors to gaining new knowledge and does not only identify problems encountered but helps nurses to share good experiences. It can positively affect job satisfaction and achievement. Reflection does not have to be a lengthy or exhaustive process allowing room for student nurses or allied health to attempt reflection whilst studying as it this reflective experience that would enrich their knowledge of personal knowing and helps them to link this with patient care.
There are different strategies students and practitioner can use to facilitate reflective practice these include keeping journal log, seeking feedback from mentors and clinical supervisors, having a critical friend, making anecdotal notes having group discussion. Attending MDT meetings and going on ward rounds may also facilitate reflection as the patients are discussed at length from when they first came to the health setting and to what has happened to them since.
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